Dr. Michael Ruscio, DC is a clinician, Naturopathic Practitioner, clinical researcher, author, and adjunct professor at the University of Bridgeport. His work has been published in peer-reviewed medical journals and he speaks at conferences around the globe.
What Does Low Progesterone Look Like and When Should You Consider Taking This Hormone?
Low progesterone symptoms typically include reduced fertility, fatigue, menstrual irregularities, anxiety, and depression.
Low progesterone may result from poor gut health, stress, and/or excess weight.
Sometimes “low” progesterone is actually the result of estrogen dominance — i.e. progesterone that’s out of balance with higher levels of estrogen.
However, estrogen dominance has been overstated, and some women may actually be low in both progesterone and estrogen.
Rather than focusing entirely on progesterone, it’s important to restore balance to the whole hormonal system, as hormones work in tandem with one another.
It’s a good idea to try a gut-healthy diet, herbal treatments (e.g. Vitex agnus-castus), and stress management first, before initiating hormone replacement therapy.
If your hormone balance is off, your health and well-being can suffer. In particular, symptoms of low progesterone (a hormone produced by the ovaries) may include [1, 2, 3, 4]:
Poor sleep quality and fatigue
Mood-related premenstrual syndrome symptoms (particularly anxiety and depression)
Premenstrual bloating, headaches, and breast tenderness
Decreased fertility, miscarriage/early labor, and ectopic pregnancy
Irregular menstrual cycles
Because progesterone also promotes the function of GABA (a calming neurotransmitter) , other signs of low progesterone can include negative mood changes, such as anxiety, and insomnia.
Common culprits of low progesterone are poor gut, hormonal, and/or metabolic health. In the majority of cases, addressing low progesterone involves restoring balance to multiple body systems, rather than fixating on a singular hormone as the problem.
“Low” progesterone symptoms that are actually due to a relative excess of estrogen are also likely to include heavy and painful or irregular periods, fibroids, endometriosis, and PMS. We’ll get into the distinction and relationship between progesterone and estrogen later.
Balancing all hormones can effectively be addressed through diet, stress reduction, and natural supplements before jumping into hormone replacement therapy.
What is Progesterone?
Progesterone is one of the principal hormones that regulate a woman’s menstrual cycle and reproductive health.
It is made by the ovaries and adrenal glands and is derived from cholesterol, which is one good reason to include some healthy fat in the diet.
During a normal menstrual cycle, progesterone levels stay low in the first half of the cycle but rise significantly in the second half (following ovulation).
The reason progesterone rises after ovulation is to prepare the womb (uterus) for a potential pregnancy. The hormone thickens up the lining of the womb (called the endometrium) to receive and nourish a fertilized egg .
If no fertilized egg implants in the lining of the uterus, progesterone levels start to drop again at or around 21 days, causing the uterine lining to shed and menstrual bleeding about seven days later.
Causes of Low Progesterone Symptoms
If you have low or unbalanced progesterone levels it’s vital to understand why.
Some underlying health issues that can result in low or unbalanced progesterone include [7, 8, 9]:
Polycystic ovary syndrome (PCOS)
Gut microbial imbalances
Low progesterone is more likely in your 40s and beyond (due to menopause), but can occur at any age.
Stress is a Factor
Being very stressed can also lead to lower progesterone production and low levels of the hormone. This is because stress involves your body producing cortisol, which it does using the same raw materials that make progesterone.
When you are highly stressed the body needs more of those raw materials to make cortisol, which leaves less available for making progesterone .
Your Gut Can Affect Your Hormonal Balance
Research suggests that underlying poor gut health may play a role in imbalances of hormones (including progesterone) and vice versa. For example:
Gut dysbiosis (bacterial imbalances) can impair the breakdown of estrogen, and lead to estrogen dominance (relatively low progesterone), or other estrogen-related conditions .
Constipation can worsen this effect as it gives the body more time to reabsorb estrogen metabolites into the bloodstream .
Unbalanced estrogen and progesterone are known to play a role in abdominal pain or bloating  and may be an underlying cause of IBS .
Hormone-related health conditions such as polycystic ovary syndrome (PCOS) and breast cancer have also been associated with low bacterial diversity in the digestive tract .
Though we still have a lot to learn about the gut–hormone relationship, there is clearly a two-way relationship between them. To balance hormone levels, it therefore makes sense to improve gut health with a healthy diet and a good probiotic supplement.
What Does Your Progesterone Level Mean?
Healthy progesterone levels measured in the luteal phase (second half) of the menstrual cycle can vary between 2 and 25 ng/ml . Levels below 3 ng/ml at day 21 likely indicate a woman has not ovulated (released an egg) , while levels closer to 10-15 ng/ml may better support fertility .
Typically, progesterone levels will decrease in perimenopause, remaining low after menopause. During a successful pregnancy, progesterone levels stay high.
However, there’s a huge variation in what is enough progesterone for each individual woman. Getting fixated on levels of progesterone (or indeed any other single hormone) isn’t helpful.
Instead, it’s important to evaluate progesterone in terms of clinical symptoms experienced, rather than values measured in the lab. It’s also important not to consider progesterone in isolation but in terms of your reproductive hormone status as a whole.
Progesterone’s Relationship with Estrogen
More specifically, progesterone is in constant flux and balance with estrogen (another vital sex hormone in the female body). When we talk about low progesterone levels and/or symptoms of low progesterone, this can actually refer to:
Low progesterone & low estrogen (quite common in thin women and may not require intervention depending on whether symptoms are present)
Low progesterone & normal estrogen
Low or normal progesterone with elevated estrogen (estrogen excess)
While all of these can be referred to as estrogen “dominance”, it’s the third one (estrogen excess) that you’ll probably have heard about the most. But in my experience, the other forms of estrogen dominance are an over-diagnosed condition, resulting in some women taking progesterone to balance “excess” estrogen unnecessarily.
In fact, I’d go further and say I’ve seen a number of women who were encouraged to take progesterone hormone alone who were actually also showing symptoms of estrogen insufficiency (low libido, migraines, night sweats, etc.).
Rather than fixating on increasing progesterone alone, these women may just need a simple herbal supplement and some lifestyle adjustments to balance all female hormones.
That being said, there are women with low progesterone symptoms, coupled with low lab values, who benefit from temporary progesterone hormone replacement therapy. This is best done while naturally addressing either low or elevated estrogen levels (and low progesterone) to restore balance to the whole endocrine system.
Why Has Estrogen Been so Vilified?
Most of the bad rap about estrogen came from the Women’s Health Initiative in 2002. This randomized clinical trial suggested that participants who received estrogen/progesterone hormone replacement therapy had an increased risk of breast cancer but no benefits to their heart health.
However, a deeper dive into the research suggests the downsides may have occurred because the women who received HRT in this study were older and on the medication for a long time — on average age 63 and over 10 years out from menopause.
They also received synthetic hormones that have largely been replaced by bioidentical ones, which may have contributed to the higher cancer risk .
Later research shows that when women start appropriate hormone replacement no later than six years after menopause, they don’t experience the same breast cancer risk and actually have a lower heart attack and stroke risk .
When Low Progesterone Is a Problem
With all this confusion surrounding estrogen dominance, how do you know when low progesterone is an actual problem that needs solving?
The answer is that it’s best not to rely on lab results alone (though they can of course be helpful) but to look at your symptoms.
And in case you missed it in the intro, low progesterone symptoms can typically include [1, 2, 3, 4]:
Infertility and miscarriage
Now let’s get into ways to fix low levels of this hormone.
Increasing Progesterone Levels Naturally
Even when it’s pretty clear that you have low progesterone levels, embarking on progesterone therapy without first trying some simple diet and lifestyle steps can be like using a sledgehammer to crack a nut. Jumping straight into HRT can also distract from the true problem, which may be underlying gut issues, stress, being overweight, etc.
If you have low progesterone symptoms or any other sort of hormonal imbalance, these three simple steps may address the issue without the need for hormones.
Eat a Healthy (Not Low Fat) Diet
A whole-food, anti-inflammatory diet can support healthy hormone balance by optimizing the gut microbiome, ensuring you get enough essential nutrients, and stabilizing blood sugar levels.
You should of course stay alert to any foods your gut is sensitive to (even if “healthy”), and avoid these while they still cause any discomfort.
Including healthy fats (essential for manufacturing hormones including progesterone) is important. For example, unprocessed meat, fish, nuts, and oils such as coconut and olive oil are all good to include in your diet in modest amounts.
Paleo or Keto: Good Diets to Try
Many of my patients with minor hormone imbalances do well on a Paleo-style diet that embraces many of the above principles. However, preliminary new research suggests a ketogenic (keto) diet, which focuses more heavily on healthy fats with low carbohydrates, may be an even more helpful choice for stubborn hormone imbalances including low progesterone or estrogen dominance.
In one study involving 25 obese young women with PCOS, a ketogenic diet for 3 months resulted in a significant decrease in weight, along with a much-reduced incidence of insulin resistance and increased progesterone levels. The average monthly peak of progesterone before the ketogenic diet was just 3.4ng/ml, compared with 20 ng/ml after. All the women reached levels of progesterone that would be sufficient to sustain a pregnancy .
Whether the same result would have been reached if the women had lost the same weight some other way (not the keto diet) is uncertain, as no control group was used. But these results were remarkable nonetheless.
Deal With Stress
Tackling stressors is another important lifestyle strategy to ensure your body doesn’t divert too many of its resources into making cortisol hormone rather than important sex hormones such as progesterone.
Cognitive behavioral therapy (CBT) and coping skills training have been shown to improve some specific symptoms of hormone imbalance such as PMS symptoms [20, 21]. But simple, free interventions such as deep breathing, mindfulness, and meditation are also very effective ways to manage stress levels. Doing some regular exercise and sticking to a regular bed and waking time so you get a better night’s sleep will also help dial down your stress levels.
Take Herbal Supplements
Another way to nudge hormones, including lower progesterone, into balance without the use of hormones is with herbal supplements like Vitex agnus-castus (chasteberry) [22, 23, 24, 25] or the Estro-Harmony or Progest-Harmony products.
Although it would do no harm to have either of these herbal blends, we recommend Progest-Harmony regularly for people whose progesterone is low relative to their estrogen levels. The key ingredients in this product are:
Chaste berry extract (Vitex agnus-castus)
Licorice root extract
Peony root extract
Research indicates that this combination may balance hormones in a safe and effective way and can:
Soothe hot flashes and other menopausal symptoms [26, 27]
The good thing about these herbal blends is that they act as adaptogens. This means that it does not matter too much if your estrogen or progesterone levels are high or low, as the herbs work to bring you back to balance.
When is it Right to Take Progesterone Hormone?
One time when it is really important to take progesterone is if you are also taking estrogen. This is because, for women who still have a uterus, estrogen-only therapy can increase endometrial cancer risk. Taking progesterone alongside reduces this risk .
In all other situations, deciding if progesterone is right for you should be based on your symptoms, in conjunction with your lab results, and the appropriate medical advice. Ideally, you will talk this through with your doctor or trusted healthcare provider.
Ideally, we suggest that you consider HRT only after you have healed your gut, cleaned up your diet, started an exercise regimen, and tried hormone-balancing botanicals.
If you have already started taking progesterone but don’t feel better (or, in the light of this article are questioning whether it is right for you), there’s no need for undue concern.
A 2020 review of progesterone concluded that in non-pregnant women “there are no serious and virtually no side effects with oral micronized progesterone therapy” .
Note, however, that the authors specifically state oral micronized progesterone, which is the bioidentical form approved by the FDA (brand name Prometrium).
Synthetic forms of oral progesterone, called progestins, don’t have such a good safety profile, especially when taken at high doses .
“Personalized” bioidentical hormones from internet providers may have untested, unapproved products according to the North American Menopause Society, so some caution is needed . Many OTC progesterone creams contain wild yam as the main component, have no actual progesterone in the formulation, and are ineffective at raising progesterone levels.
If you are interested in taking bioidentical/micronized progesterone, I’d suggest working with a specialist functional health doctor to get the right dose and formulation for you.
Progesterone in Context
To summarize, progesterone is a hormone that can’t be considered in isolation. For example, low progesterone symptoms can sometimes occur when progesterone levels are actually normal, but estrogen is elevated.
Low progesterone can also occur while estrogen is low or normal. Rather than worry about achieving “normal” lab values for these hormones, it’s important to look at your symptoms instead and act on these.
You may be able to address low progesterone symptoms by changing your diet, learning to cope with stress, and taking herbs that help balance your hormones.
However, if you do choose to take progesterone, there are few side effects or concerns with the right bioidentical formula.
Hormone imbalances can sometimes be more complicated. If you feel you may require specialized help with your hormones, get in touch with us at the Ruscio Institute for Functional Medicine, and we will be pleased to help.
The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.
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